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Tretter JT, Spicer DE, Franklin RCG, Béland MJ, Aiello VD, Cook AC, Crucean A, Loomba RS, Yoo SJ, Quintessenza JA, Tchervenkov CI, Jacobs JP, Najm HK, Anderson RH. Expert Consensus Statement: Anatomy, Imaging, and Nomenclature of Congenital Aortic Root Malformations. Cardiol Young 2023; 33:1060-1068. [PMID: 37288941 DOI: 10.1017/s1047951123001233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Over the past 2 decades, several categorizations have been proposed for the abnormalities of the aortic root. These schemes have mostly been devoid of input from specialists of congenital cardiac disease. The aim of this review is to provide a classification, from the perspective of these specialists, based on an understanding of normal and abnormal morphogenesis and anatomy, with emphasis placed on the features of clinical and surgical relevance. We contend that the description of the congenitally malformed aortic root is simplified when approached in a fashion that recognizes the normal root to be made up of 3 leaflets, supported by their own sinuses, with the sinuses themselves separated by the interleaflet triangles. The malformed root, usually found in the setting of 3 sinuses, can also be found with 2 sinuses, and very rarely with 4 sinuses. This permits description of trisinuate, bisinuate, and quadrisinuate variants, respectively. This feature then provides the basis for classification of the anatomical and functional number of leaflets present. By offering standardized terms and definitions, we submit that our classification will be suitable for those working in all cardiac specialties, whether pediatric or adult. It is of equal value in the settings of acquired or congenital cardiac disease. Our recommendations will serve to amend and/or add to the existing International Paediatric and Congenital Cardiac Code, along with the Eleventh iteration of the International Classification of Diseases provided by the World Health Organization.
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Affiliation(s)
- Justin T Tretter
- Department of Pediatric Cardiology, Cleveland Clinic Children's and The Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Diane E Spicer
- Heart Institute, Johns Hopkins All Children's Hospital, St Petersburg, Florida
- Congenital Heart Center, UF Health Shands Hospital, Division of Cardiovascular Surgery, Departments of Surgery and Pediatrics, University of Florida, Gainesville, Florida
| | - Rodney C G Franklin
- Paediatric Cardiology Department, Royal Brompton & Harefield National Health Service Trust, London, United Kingdom
| | - Marie J Béland
- Division of Pediatric Cardiology, The Montreal Children's Hospital of the McGill University Health Centre, Montréal, Québec, Canada
| | - Vera D Aiello
- Heart Institute (InCor), University of São Paulo School of Medicine, São Paulo, Brazil
| | - Andrew C Cook
- Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Adrian Crucean
- Department of Paediatric Cardiac Surgery, Birmingham Women's and Children's Hospital, Birmingham, United Kingdom
| | - Rohit S Loomba
- Division of Cardiology, Advocate Children's Hospital, Oak Lawn, Illinois
| | - Shi-Joon Yoo
- Division of Cardiology, Department of Pediatrics, Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Christo I Tchervenkov
- Division of Cardiovascular Surgery, The Montreal Children's Hospital of the McGill University Health Centre, Montréal, Québec, Canada
| | - Jeffrey P Jacobs
- Congenital Heart Center, UF Health Shands Hospital, Division of Cardiovascular Surgery, Departments of Surgery and Pediatrics, University of Florida, Gainesville, Florida
| | - Hani K Najm
- Division of Pediatric Cardiac Surgery, Cleveland Clinic Children's and the Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Robert H Anderson
- Cardiovascular Research Centre, Biosciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
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Tretter JT, Spicer DE, Franklin RCG, Béland MJ, Aiello VD, Cook AC, Crucean A, Loomba RS, Yoo SJ, Quintessenza JA, Tchervenkov CI, Jacobs JP, Najm HK, Anderson RH. Expert Consensus Statement: Anatomy, Imaging, and Nomenclature of Congenital Aortic Root Malformations. Ann Thorac Surg 2023; 116:6-16. [PMID: 37294261 DOI: 10.1016/j.athoracsur.2023.03.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 02/03/2023] [Accepted: 03/15/2023] [Indexed: 06/10/2023]
Abstract
Over the past 2 decades, several categorizations have been proposed for the abnormalities of the aortic root. These schemes have mostly been devoid of input from specialists of congenital cardiac disease. The aim of this review is to provide a classification, from the perspective of these specialists, based on an understanding of normal and abnormal morphogenesis and anatomy, with emphasis placed on the features of clinical and surgical relevance. We contend that the description of the congenitally malformed aortic root is simplified when approached in a fashion that recognizes the normal root to be made up of 3 leaflets, supported by their own sinuses, with the sinuses themselves separated by the interleaflet triangles. The malformed root, usually found in the setting of 3 sinuses, can also be found with 2 sinuses, and very rarely with 4 sinuses. This permits description of trisinuate, bisinuate, and quadrisinuate variants, respectively. This feature then provides the basis for classification of the anatomical and functional number of leaflets present. By offering standardized terms and definitions, we submit that our classification will be suitable for those working in all cardiac specialties, whether pediatric or adult. It is of equal value in the settings of acquired or congenital cardiac disease. Our recommendations will serve to amend and/or add to the existing International Paediatric and Congenital Cardiac Code, along with the Eleventh iteration of the International Classification of Diseases provided by the World Health Organization.
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Affiliation(s)
- Justin T Tretter
- Department of Pediatric Cardiology, Cleveland Clinic Children's and The Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Diane E Spicer
- Heart Institute, Johns Hopkins All Children's Hospital, St Petersburg, Florida; Congenital Heart Center, UF Health Shands Hospital, Division of Cardiovascular Surgery, Departments of Surgery and Pediatrics, University of Florida, Gainesville, Florida
| | - Rodney C G Franklin
- Paediatric Cardiology Department, Royal Brompton & Harefield National Health Service Trust, London, United Kingdom
| | - Marie J Béland
- Division of Pediatric Cardiology, The Montreal Children's Hospital of the McGill University Health Centre, Montréal, Québec, Canada
| | - Vera D Aiello
- Heart Institute (InCor), University of São Paulo School of Medicine, São Paulo, Brazil
| | - Andrew C Cook
- Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Adrian Crucean
- Department of Paediatric Cardiac Surgery, Birmingham Women's and Children's Hospital, Birmingham, United Kingdom
| | - Rohit S Loomba
- Division of Cardiology, Advocate Children's Hospital, Oak Lawn, Illinois
| | - Shi-Joon Yoo
- Division of Cardiology, Department of Pediatrics, Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Christo I Tchervenkov
- Division of Cardiovascular Surgery, The Montreal Children's Hospital of the McGill University Health Centre, Montréal, Québec, Canada
| | - Jeffrey P Jacobs
- Congenital Heart Center, UF Health Shands Hospital, Division of Cardiovascular Surgery, Departments of Surgery and Pediatrics, University of Florida, Gainesville, Florida
| | - Hani K Najm
- Division of Pediatric Cardiac Surgery, Cleveland Clinic Children's and the Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Robert H Anderson
- Cardiovascular Research Centre, Biosciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
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Tretter JT, Izawa Y, Spicer DE, Okada K, Anderson RH, Quintessenza JA, Mori S. Understanding the Aortic Root Using Computed Tomographic Assessment: A Potential Pathway to Improved Customized Surgical Repair. Circ Cardiovasc Imaging 2021; 14:e013134. [PMID: 34743527 DOI: 10.1161/circimaging.121.013134] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
There is continued interest in surgical repair of both the congenitally malformed aortic valve, and the valve with acquired dysfunction. Aortic valvar repair based on a geometric approach has demonstrated improved durability and outcomes. Such an approach requires a thorough comprehension of the complex 3-dimensional anatomy of both the normal and congenitally malformed aortic root. In this review, we provide an understanding of this anatomy based on the features that can accurately be revealed by contrast-enhanced computed tomographic imaging. We highlight the complimentary role that such imaging, with multiplanar reformatting and 3-dimensional reconstructions, can play in selection of patients, and subsequent presurgical planning for valvar repair. The technique compliments other established techniques for perioperative imaging, with echocardiography maintaining its central role in assessment, and enhances direct surgical evaluation. This additive morphological and functional information holds the potential for improving selection of patients, surgical planning, subsequent surgical repair, and hopefully the subsequent outcomes.
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Affiliation(s)
- Justin T Tretter
- Heart Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, OH (J.T.T.)
| | - Yu Izawa
- Division of Cardiovascular Medicine, Department of Internal Medicine (Y.I.), Kobe University Graduate School of Medicine, Japan
| | - Diane E Spicer
- Heart Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL (D.E.S., J.A.Q.)
| | - Kenji Okada
- Department of Cardiovascular Surgery (K.O.), Kobe University Graduate School of Medicine, Japan
| | - Robert H Anderson
- Cardiovascular Research Centre, Biosciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom (R.H.A.)
| | - James A Quintessenza
- Heart Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL (D.E.S., J.A.Q.)
| | - Shumpei Mori
- UCLA Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine at UCLA (S.M.)
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Izawa Y, Mori S, Tretter JT, Quintessenza JA, Toh H, Toba T, Watanabe Y, Kono AK, Okada K, Hirata KI. Normative Aortic Valvar Measurements in Adults Using Cardiac Computed Tomography - A Potential Guide to Further Sophisticate Aortic Valve-Sparing Surgery. Circ J 2021; 85:1059-1067. [PMID: 33408304 DOI: 10.1253/circj.cj-20-0938] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND A thorough understanding of the anatomy of the aortic valve is necessary for aortic valve-sparing surgery. Normal valvar dimensions and their relationships in the living heart, however, have yet to be fully investigated in a 3-dimensional fashion.Methods and Results:In total, 123 consecutive patients (66±12 years, Men 63%) who underwent coronary computed tomographic angiography were enrolled. Mid-diastolic morphology of the aortic roots, including height of the interleaflet triangles, geometric height, free margin length of each leaflet, effective height, and coaptation length were measured using multiplanar reconstruction images. Average height of the interleaflet triangle, geometric height, free margin length, effective height, and the coaptation length were 17.3±1.8, 14.7±1.3, 32.6±3.6, 8.6±1.4, and 3.2±0.8 mm, respectively. The right coronary aortic leaflet displayed the longest free margin length and shortest geometric height. Geometric height, free margin length, and effective height showed positive correlations with aortic root dimensions. Coaptation length, however, remained constant regardless of aortic root dimensions. CONCLUSIONS Diversities, as well as characteristic relationships among each value involving the aortic root, were identified using living-heart datasets. The aortic leaflets demonstrated compensatory elongation along with aortic root dilatation to maintain constant coaptation length. These measurements will serve as the standard value for revealing the underlying mechanism of aortic regurgitation to plan optimal aortic valve-sparing surgery.
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Affiliation(s)
- Yu Izawa
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Shumpei Mori
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Justin T Tretter
- The Heart Institute, Cincinnati Children's Hospital Medical Center.,Department of Pediatrics, University of Cincinnati College of Medicine
| | - James A Quintessenza
- The Heart Institute, Cincinnati Children's Hospital Medical Center.,Kentucky Children's Hospital, University of Kentucky, UK Healthcare
| | - Hiroyuki Toh
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Takayoshi Toba
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Yoshiaki Watanabe
- Department of Radiology, Kobe University Graduate School of Medicine
| | - Atsushi K Kono
- Department of Radiology, Kobe University Graduate School of Medicine
| | - Kenji Okada
- Department of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | - Ken-Ichi Hirata
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
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